Sick of Cheesecake

In a well-publicized and well-written article in the New Yorker, Atul Gawande (one of my doctor writing heroes) talks about his visit to the popular restaurant, The Cheesecake Factory, and how that visit got him thinking about the sad state of health care.

The chain serves more than eighty million people per year. I pictured semi-frozen bags of beet salad shipped from Mexico, buckets of precooked pasta and production-line hummus, fish from a box. And yet nothing smacked of mass production. My beets were crisp and fresh, the hummus creamy, the salmon like butter in my mouth. No doubt everything we ordered was sweeter, fattier, and bigger than it had to be. But the Cheesecake Factory knows its customers. The whole table was happy (with the possible exception of Ethan, aged sixteen, who picked the onions out of his Hawaiian pizza).

I wondered how they pulled it off. I asked one of the Cheesecake Factory line cooks how much of the food was premade. He told me that everything’s pretty much made from scratch—except the cheesecake, which actually is from a cheesecake factory, in Calabasas, California.

I’d come from the hospital that day. In medicine, too, we are trying to deliver a range of services to millions of people at a reasonable cost and with a consistent level of quality. Unlike the Cheesecake Factory, we haven’t figured out how. Our costs are soaring, the service is typically mediocre, and the quality is unreliable. Every clinician has his or her own way of doing things, and the rates of failure and complication (not to mention the costs) for a given service routinely vary by a factor of two or three, even within the same hospital.

I think you get the idea: if only medicine were run more like the Cheesecake Factory, health care would cost much less and do much more good. His story about how orthopedic care can be made into a system are spot on. Disorganization of care is a huge area of waste in the system (which a recent Institutes of Medicine report likely underestimates - in my opinion - at $750 billion per year), and deliberate systemization is the only way to overcome this problem. I think his analogy is good, his writing is (as always) eloquent, and following his recommendation would save a lot of money and many lives.

But there is one problem with this article: it misses the main problem in health care. His system deals mainly with hospital medicine, which is, for lack of a better name, sick care instead of health care. The mis-labeling of sick care as "health care" is, in my view, the most costly error in all of medicine.

Let's back up to the restaurant analogy to see where this confusion causes havoc. The goals of the Cheesecake Factory, like any restaurant are:

To give the best food as cheaply as possible

To give a good customer experience that brings people back repeatedly and attracts new customers

To keep overhead low without compromising #1 and #2

It is point #2 where the health care analogy breaks down. People want to go to eat at restaurants (for full disclosure, I am a big fan of the Cheesecake Factory and have adipose tissue to verify this fact), whereas they don't want to go to the hospital. Yet the "health care" system is not set up with this in mind. Like the restaurant industry, "health care" is set up to deal with episodes of care, usually centered around illness or injury. The more people are sick, the more opportunities for income for the medical industry. This means that to truly succeed as an industry, "health care" has to do the following:

Give the "best" care as cheaply as possible

To take measures to maximize the number of encounters a person has with the system

To minimize overhead.

Gawande's article focuses on #1 and #3, ignoring the glaring problem in #2. The other problem the analogy ignores is the definition of the word "best." Is the "best" drug for your heartburn a cheap antacid, or is it the $120 bottle of Nexium? Is the "best" surgery for you the standard procedure, or is it the one using the cutting-edge Da Vinci robot? Is the "best" care in primary care a SMA-20 blood panel, an EKG, CBC, and PSA (or mammogram) every year, or is it a frank discussion with your PCP about lifestyle changes? Clearly from a business standpoint, like the restaurant industry, "health care" makes the most money from more, not less.

The 600 pound (Robotic Da Vinci) gorilla in the room is the assumption is that "health care" is, at best, a fixed commodity with a set amount of consumption by "health consumers." At worst, "health care" is viewed, like restaurants, as a growth industry. While it may be in my best interests to minimize my encounters with the Cheesecake Factory, I go there because I want to. "Health Care," on the other hand, is something I hope to avoid, as I would also try to avoid encounters with auto mechanics and plumbers.

As a PCP (especially in my new practice), my goal is to decrease my patients' encounters with the rest of the health care industry. In this way, the analogy with Cheesecake Factory is unwittingly accurate. More is usually not better in health care, and the flawed belief in the more mantra is the basis for the spending that is out of control, now fueled by a hungry industry that perpetuates that mantra. This is quite similar in the more mantra pushed by the food and restaurant industry, a mantra I do well to get my patients ignore as well.

Health care needs to become centered on health, not on sickness. It needs to be focused on less consumption, not more. This will not be good news for our current "health care" industry - the one built around sickness, not health - but will instead close hospitals, turn specialists into primary care physicians, and put many "health related service" companies out of business. Healthy patients (the purported goal of "health care") will be extraordinarily unhealthy for the "health care" industry.

There still will be need for sick care, and I sincerely hope that Dr. Gawande's dream of a lean and efficient system is realized for this. But limiting the focus on improving the process of dealing with illness won't stop the main problem: we are eating way too much cheesecake.